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Jun 22 01 04: 08p n Jones 5-9451 p. 1 <br /> 05/22/2001 15:51 2091 93DE570 ATC 'c G1 <br /> San Joaquin County'Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �� N"i"�'� �''�``�' PERMIT SR#; i <br /> LICENSED CONTRACTORS DECLARATION (L(-,D) <br /> I hereby efflrm thel 1 am licensed under the provisions of Chapter 9(cwtirrmenGng with Section 7000)of Dlvislon <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Ucense C%�� 1� `? Expiration Date: <br /> Date. ;n ,� :� l _Contractor, _—1 �` !1 ._� 1��11(�C,,��ti�`1 �1_{✓'---- <br /> Signature Title <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> i hereby affirm under penalty of perjury one of the following di-c4afetlons' (CHECK ALL THAT APPLY) <br /> _i have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the per?ormance of the work for which this permit is issued. <br /> ^;-have and will mainia'n workers'compensation lmrsnce,el 'equir*d by Section 3700 of the Labor Code, <br /> for the pertermence of the we!k for which this permit is issued. My workers'compensatior:insurence <br /> carrier and policy numbers a,e� <br /> Carrier: _? Policy Number: i L} IAL,�, 1 1 <br /> I certify that In the perfotmance of the work for which this permit is Issued. I shall not employ any per5or)n <br /> any manner so as to become Subject to the workers'compensation laws of Cgtlfornna,and agree 1:191 d <br /> should become 5ubjoct to the workere'compon3at;on provisions of Section 3740 of the Labor Code. i ansa <br /> forthwith comply with those provisions. <br /> � <br /> / <br /> Date: �7 i `. l _Signature:, <br /> _ <br /> 11 <br /> Printed Name: / i <br /> WARNING:FAILURE 70 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT ! <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS � <br /> {5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 Of THE LABOR CODE. <br /> w� iii :<<�,%1 (C•57licensed aut'torited representative),hereby i <br /> to eign this San Joaquin County Well Permit Application on my trehalf. I understand this uL-thoriaatlon Is vatld for <br /> one(1)year and If limited to the work plan dated on the froni page of thle application. <br /> S-tT-2000 J AAI �. <br />